Nurse anaesthetists’ experiences of the first intraoperative meeting with anxious adult patients: An interview study

Abstract

The first intraoperative meeting between the nurse anaesthetist and the patient is usually brief. The short encounter requires nursing competence and it is important to build rapport with the patient. Organizational aspects such as shortage of time can affect the first encounter. The aim of the study was to elucidate nurse anaesthetists’ experiences of the first intraoperative meeting with anxious adult patients. A qualitative content analysis was conducted. Ten nurse anaesthetists were interviewed using open-ended questions. The theme ‘To address’ emerged from three categories: Situations that can affect how to address patient anxiety, Strategies on how to address patient anxiety and Experiences of addressing patient anxiety. The study showed that it became easier with professional experience to address patient anxiety. The most prominent findings were the differences in how to address patient anxiety, with either medical or nursing interventions.

Introduction

Perioperative care is care provided during the pre-, intra- and postoperative period.^1,2 The intraoperative period begins upon the patient’s arrival at the operating room and ends when the patient is transferred to the post-anaesthesia care unit. ³ The first intraoperative encounter between the nurse anaesthetist (NA) and the patient is usually brief. The short meeting requires nursing competence and it is important to build rapport with the patient.

The perioperative dialogue is an organizational model for perioperative care based on Lindwall and Von Post’s nursing theory ² which is inspired by Eriksson’s theory of caritative care, caritas; both of which have a foundation of ethical principles built on compassion, dignity and respect for mankind. It is defined as pre-, intra- and postoperative encounters where information is exchanged, and enables planning of nursing interventions to optimize individualized intraoperative care. Research has shown that NAs experienced continuity with the perioperative dialogue, which facilitated nursing care. ⁴

In Benner’s book From novice to expert, nurses’ experience is viewed as consisting of five levels of proficiency. ⁵ The novice, is a nurse with no or limited experience. The advanced beginner makes decisions based on professional experience. The third stage, competent, is a nurse with a few years of experience. Proficient nurses can identify unexpected situations and prioritize interventions. The fifth stage, expert, makes decisions and interventions based on clinical competence.

It is stated in the Swedish description of competence for registered nurses with a graduate degree in nursing – specialized in anaesthetic care, that evidence-based nursing and a safe setting where the patients’ needs and autonomy are in focus are of importance. ⁶ However, this can be difficult to accommodate, due to stress in the work environment. ⁷ Stressful situations can lead to negative feelings such as anger, frustration and guilt, which can affect NAs’ professional and personal lives. ⁸ Organizational aspects, staffing situations and education are factors that can affect NAs in their profession. ⁹ Production pressure, high workload and less time to perform tasks can lead to stress and discontent. ¹⁰ Sufficient time for each patient is essential, but can be challenging to obtain.^11,12 An increase of patients in surgical departments can lead to less time for comforting conversations. ¹³ Such encounters can be of importance to gain trust and provide assurance. ¹⁴ Nonetheless, it is essential to provide time for a dialogue between the NA and the patient, regardless of the surgical department’s organizational structure. ³

Previous experiences of health care, personal maturity and susceptibility are factors that can affect levels of perioperative anxiety. ¹⁴ Patients’ thoughts regarding general health, the surgical procedure, the postoperative period and concerns about future outcomes can cause apprehension. ¹⁵ Patients can express fear of undergoing anaesthesia,^15–17 specifically concerning induction of general anaesthesia and of anaesthesia medication. ¹⁶ Uncertainties about not regaining consciousness can lead to preoperative anxiety. ¹⁷ Fear of losing control, harm to the body or death due to surgical complications can cause apprehension. ¹⁸ A recent study showed that patients who experienced negative remarks during the preoperative assessment, perceived higher levels of pain and anxiety during anaesthesia. ¹⁹ Patients who had been addressed in a positive manner felt trust and assurance in the NA’s qualifications and credibility, as well as reduced anxiety.

A less successful first encounter, where the patient is anxious and unattainable, can have negative consequences on anaesthesia. ¹⁴ Physiological effects of anxiety are fluctuating heart rate and elevated blood pressure and patients who show signs of stress can require higher dosages of medication during anaesthesia.^{14,16,20–21} Unfavourable experiences of the first intraoperative encounter can lead to negative memories for patients, and feelings of dissatisfaction for both NAs and patients. Research has shown that a NA could overestimate patient anxiety, while an anaesthesiologist could underrate such situations. ²² To gain the patient’s trust, it is therefore of importance to have a dialogue regarding both positive and negative experiences.

It is essential to perceive and accommodate individual needs. ⁴ It is important to listen to the patient, show empathy and acknowledge experiences of losing control. ¹⁹ There is a correlation between high levels of anxiety and inadequate preoperative information. ¹⁶ Therefore, it is important to provide thorough information. NAs can use diversion methods, such as relaxing music to reduce anxiety. Anxiolytics can be an option to relieve anxiety.^16,23 A positive approach can be of importance, to provide trust and security for the patient and their next of kin. ⁹ Patients who felt safe during anaesthesia induction expressed trust in the NA. ¹⁹ This could facilitate the patient submitting to the NA’s care and have favourable effects on the postoperative phase. ³ The patient submits both body and soul and it is essential to consider both as one component. ²⁴

There are several papers from patients’ perspectives on the first encounter with the NA.^16,19,22 However, there is limited research on NA experiences of the first meeting with anxious adult patients in the intraoperative setting. Previous papers are at a master’s degree level.^25–27 These studies have shown that it is essential to act in a calm and professional manner, to consider individual needs, customize information and provide physical contact. The current study is important for aspiring or inexperienced NAs to obtain knowledge and understanding, considering that patient anxiety is a daily occurrence in perioperative nursing. Research has shown that high workload and insufficient time are common in the perioperative setting, nontheless, it is equally important to address anxiety individually.^12,14 Therefore, it is of importance to highlight NA experiences of the first encounter with anxious adult patients.

Aim

The aim of the present study was to elucidate nurse anaesthetists’ experiences of the first intraoperative meeting with anxious adult patients.

Materials and methods

Design and sample

A qualitative design was conducted to gain comprehension of the individuals’ experiences regarding the phenomena of patient anxiety. ²⁸ This design allows data to be obtained through interviews, where the informants’ experiences are analysed and interpreted. A qualitative interview study is conducted with a small number of informants, and focuses on the meeting between the interviewer and the informant. ²⁹ In our study, ten NAs from four anaesthesia departments at two university hospitals in Sweden were included. Inclusion criteria were NA with a minimum of two years’ professional experience. NAs with exclusive experience of paediatric patients were excluded. Informants were recruited through information meetings held at the anaesthesia departments. In addition, an information letter regarding the study and the need of informants was sent via email to the anaesthesia departments. The authors aimed to use a strategic selection with a variation of age, sex and professional experience. ³⁰ The informants were between 31 and 62 years of age, with 4 to 38 years of professional experience. One male NA participated in the study.

Ethical considerations

Ethical advising was obtained from the Board of Nursing Science Ethical Committee at Lund University, which is the normal procedure at our university and written consent was attained (VEN 6-14, 2015). Written approvals were received from the directors at the hospitals. The informants received verbal and written information, and a letter of consent.

Data collection and analysis

Data were collected from January to March 2014. The interviews lasted between 20 and 55 minutes and were conducted in secluded locations. A pilot interview was performed to evaluate whether questions in an interview guide were applicable (see Appendix 1). The interview guide was used in its original format and the pilot interview was included in the study. The authors avoided questions that were too specific, which could affect the interaction, ²⁹ and asked the questions in the order that suited the dialogue. Two e-book readers were used to digitally record the interviews. In addition to the voice recording the authors took notes during the interviews, ³¹ and documented body language, gestures and the atmosphere. The data was transcribed verbatim. The informants received a number to ensure confidentiality. ³²

A qualitative content analysis method inspired by Graneheim and Lundman and Lundman and Hällgren Graneheim was conducted.^33,34 At first the interviews were read separately on several occasions to obtain an overall impression of the text. A manifest content analysis method was used to describe the content of the data. The authors found meaning units, which were words and sentences that were relevant to the aim of the study. The meaning units were reduced to condensed meaning units and codes could be extracted. The codes were compared according to similarities and differences and seven subcategories were obtained. Attained data were inserted into tables. The authors discussed their individual findings and three categories emerged. Data were interpreted to find the underlying profound content and one theme emerged. The authors used both a manifest and a latent content analysis method to describe and interpret the text to find a greater understanding of the data.^33,34 Both methods were significant in finding differences and similarities in the data.

Results

After analysing the text, the theme ‘To address’ emerged. The theme was the core in the text and covered the following three categories: Situations that can affect how to address patient anxiety, Strategies on how to address patient anxiety and Experiences of addressing patient anxiety. The three categories emerged from seven subcategories: Time and environment, Pre- and postoperative encounters, To interpret signs of anxiety, Nursing interventions, Medical interventions, Patient anxiety and Developing professional anaesthesia nursing care.

Situations that can affect how to address patient anxiety

Time and environment

The importance of sufficient time for preparation and planning of nursing interventions in a hectic work environment emerged. The NAs experienced that they often had to retrieve information from medical records and prepare for the next patient, while performing anaesthesia on another. The informants found it difficult to advocate the need for time in the beginning of their careers since their professional role was not established. NAs with increased experience found it easier to justify the need for time for the first meeting. However, insufficient time and high workloads could affect the first encounter and how intraoperative anxiety was addressed.

Can’t I just put the blanket on properly? I can’t just throw it on like that. Of course it will affect how I act and how I appear. But you just have to try to joke around a little. You can say something like; now we have to speed things up.

The work environment could affect the first encounter. The area where the first meetings took place was unfavourable and it could be difficult to have private conversations. Stressful situations could compromise the patient’s integrity and confidence in the NA. Such situations could lead to NAs feeling stressed and inadequate. Informants with increased experience expressed that they often felt less patience for such an environment.

There’s a lot of going in and out of the OR. Then there’s the preoperative holding area outside of the OR, where there aren’t even any walls. There are just curtains. I feel bad for the patients. They aren’t getting the peace and quiet that they deserve.

Pre- and postoperative encounters

All informants aspired to have preoperative encounters. A preoperative meeting with an anxious patient could optimize the intraoperative encounter, which could be favourable for both NA and patient. It could be reassuring for the patient to meet a familiar person in the intraoperative setting, and the NA could prepare for how to address the patient’s anxiety. Furthermore, the informants aspired to meet with patients in the postoperative period. A postoperative encounter could enable patient feedback, which could contribute to professional improvement.

Both preoperative and postoperative dialogues are great ways to improve as a nurse anaesthetist. You have already met the patient, and you know that the patient is very nervous. You think to yourself, well then I’ll do things this way. It would also be great for the patients.

Strategies on how to address patient anxiety

To interpret signs of anxiety

The informants assumed that all patients were anxious prior to surgery. It was important to perceive signs of anxiety and plan strategies on how to address individual needs. The NAs experienced that anxiety could be expressed in various ways. Some patients would conceal their anxiety by acting calm or talking exaggeratedly. Others expressed it physically, were unattainable or used foul language. The NAs needed to be resourceful to manage difficult situations with anxious patients. Cultural background could influence how preoperative anxiety was expressed. It was essential to obtain knowledge and understanding to address the patients individually. Increased experience made it easier to distinguish such needs.

It doesn’t mean that they are more anxious than anyone else. They just express themselves differently. You just have to take this into consideration and learn how to respect it.

NAs with several years of professional experience expressed that it became easier to perceive signs of anxiety and plan individual nursing strategies. Experience provided confidence, which could facilitate difficult encounters with anxious patients.

It’s a lot easier with work experience. You see the signs right away.

Nursing interventions

It was important to build rapport with the patient and to get acquainted with individual preferences. It enabled planning of nursing interventions, which could facilitate the intra- and postoperative period. The informants experienced that it was essential to identify and avoid sensitive topics. It was equally important to show sympathy and empathy. The NA would address anxiety by providing safety and assurance. An approachable body language, calming conversations, providing information and a soothing environment could ease anxiety. The NA could show the patients that they cared by asking if they were comfortable on the operating table. It was essential to recognize and acknowledge fear and anxiety, and to address the patients in their current state.

It’s important to recognize the patient’s fear and to acknowledge that it’s OK to be afraid. You can say that we’re going to take over all responsibilities; ’cause we know what we are doing. Just do it for two to three minutes before you give Propofol. I think it’s really important for that person’s trust in the health care system.

Medical interventions

There were diverse opinions regarding usage of pharmaceuticals. The informants felt that medical interventions were a final option when other methods were ineffective. However, some NAs used medical interventions at an early stage. Medication could be used to make the situation bearable for the patient, such as during epidural or spinal anaesthesia. The NAs experienced that the most effective approach was a combination of professionalism, calming conversations and pharmaceuticals. NAs with increased experience valued comforting dialogues rather than medical interventions.

‘Cause what they really need is security, not Propofol. They want security and that’s easier to give.’

It emerged that it could be favourable to use medication at an early stage on patients with high levels of anxiety. It was easier with experience to distinguish when such medical interventions were required.

It’s better if it goes fast. I don’t even say anything to the patient. I just inject Fentanyl right away, as soon as we are in the OR. Then I put the patient to sleep as fast as I can.

Experiences of addressing patient anxiety

Patient anxiety

The NAs experienced that most patients were anxious of awakening during surgery or not waking up afterwards. Younger patients could worry about losing control or dying during surgery. Female patients could sometimes express anxiety over being nursed by a male NA. Patients were sometimes unable to identify what caused their concerns; sometimes it could be the entire situation. Furthermore, anxiety levels could differ depending on the surgical procedure. Cancer patients could express anxieties over the whole situation, the diagnosis and its outcome. Prior experiences of anaesthesia and health care, such as a painful insertion of an intravenous cannula and inadequate information, could cause anxiety.

The informants experienced that anaesthesiologist and NA did not always have the same opinion regarding patient anxiety. Such situations could affect information provided in the preoperative assessment. Inadequate information regarding the patient’s status could affect how the NA would approach the patient during the first intraoperative meeting. The informants did not experience any difference in anxiety among patients who received general, regional or local anaesthesia. Patients could express anxiety if there were alterations in the planned type of anaesthesia. Therefore, it was important to try to maintain the original plan. Information from media could cause apprehension and have negative influences on patients’ trust in the health care system. It was predominantly younger individuals who often searched for information on the Internet.

There were a lot of worries after Michael Jackson took his own life with Propofol. It was all over the newspaper headlines in the convenience store that Michael Jackson died because of Propofol. The patients would say; I hope you’re not going to give me Propofol ‘cause then I’ll die.

Developing professional anaesthesia nursing care

Sometimes it could be difficult to address severely ill patients and patients with high levels of anxiety. Handling challenging situation became more manageable with increased experience. The informants could feel empathy for the patients. However, it was essential to discuss difficult encounters with colleagues, to avoid emotional overload, to distance oneself and to separate one’s professional and private life. Professional experience provided confidence and enabled the NAs to give more of themselves. It emerged that inexperience made it easier to regard an unsuccessful first intraoperative encounter as personal failure.

Back then my role wasn’t that clear to me. I felt powerless. You always think that I could have done things better. But you just have tell yourself that I did my best.

Discussion

Methodological discussion

Ten NAs with varied years of professional experience were included in the study. Abundance or shortage of informants can lead to difficulties in analysing and presenting the findings. ²⁹ The authors considered it to be an adequate sample to obtain profound understanding. The authors aspired for variation in age, sex and professional experience. A limitation of the study was that there were difficulties in recruiting informants. There were an abundance of female in comparison to male NAs at the different anaesthesia departments. Therefore, most informants were women with several years of professional experience. In addition, only one male NA showed interest in participating in the study. The authors failed in their attempt to use a strategic selection, as a result of limited gender variation. A greater variation in the informants’ backgrounds could perhaps have given other results. The authors contemplated whether the questions in the interview guide were of a sensitive nature, considering inclusion of sensitive topics could affect the answers. ³¹ The interviews were digitally recorded. A disadvantage with a voice recording is the absence of facial expressions. ²⁹ It would have been favourable to film the interviews, however, this would have made it difficult to ensure confidentiality.

Discussion of findings

The essential them ‘To address’ emerged in the informants’ narratives. The findings showed that NA experiences and organizational aspects could affect how patient anxieties were addressed. There was an aspiration for sufficient time for the first intraoperative encounter. Lindwall and Von Post highlight the importance of the perioperative dialogue as an organizational model. ² The findings were consistent with previous literature, which accentuates the need for time for a dialogue between the NA and the patient. ³ Insufficient time could affect patient preparations. Similar conclusions were found in a study of NA experiences of preoperative anxiety with children, where insufficient time for preparations could cause stress. ¹¹ It emerged that NAs with increased experience were more confident in their professional role and found it easier to justify the need for time. These findings were coherent with Benner, where clinical experience in providing health care is emphasized, and the proficient nurse can assess and prioritize. ⁵ Similar results have shown that it became easier with professional experience to advocate the patient’s rights, since inexperienced NAs were often afraid of making mistakes. ³⁵ The work environment could additionally affect the first intraoperative meeting with anxious patients. Informants with increased experience felt that they were more perceptive of situations that could affect how the patients were addressed, and had less patience for a stressful environment. The findings were coherent with previous research, which shows that shortage of time can lead to negative feelings and affect the work environment.^7–8

All informants aspired for a preoperative dialogue prior to the first intraoperative meeting. However, preoperative dialogues did not occur in any of the surgical departments due to organizational aspects. A preoperative encounter could provide reassurance and security, and lead to positive experiences for the NA and the patient. The findings were coherent with Lindwall and Von Post, where the importance of the perioperative dialogue and pre- intra- and postoperative meetings is highlighted. ² Furthermore, the informants aspired for postoperative encounters, to receive feedback and improve professional competence. This can be associated to Benner, where nurses engage in establishing professionalism and confidence. ⁵ The aspiration for pre- and postoperative encounters was consistent with previous research of positive effects of the perioperative dialogue. ⁴

The study showed that it was essential to perceive signs of anxiety in order to address and plan individual interventions. Anxiety could be expressed in various ways. It was important to obtain knowledge and understanding regarding cultural differences in expressing anxiety. Professional experience provided confidence in identifying and addressing anxiety, to plan strategies and interventions. The findings were consistent with Benner, where increased experience established competence to make accurate decisions, which can facilitate individualized care. ⁵ The findings were also coherent with Lindwall and Von Post’s nursing theory, which shows the importance of nurses’ willingness to care, to be the patients’ advocate and to regard both body and soul. ²⁴ It emerged that the NAs experienced that this was essential for future trust in the health care system.

There were diverse opinions regarding anxiolytics. All informants expressed that pharmaceuticals were a final alternative when nursing interventions were unsuccessful. However, there were NAs who felt more positive towards the use of medical interventions at an early stage. Previous research has shown that medication can be administered to ease anxiety.^16,23 The findings showed that there could be situations where patients would receive medication without their knowledge. The authors contemplated whether such an approach could be in opposition to caritas, which stands on the foundation of empathy and compassion for individuals. It is questionable whether such actions are based on true compassion for the patient or due to a hectic work situation. Such an approach could be considered contradictory to NA ethical grounds and could deprive the patients of their autonomy and basic right to receive information. The importance of patient autonomy and optimizing perioperative care is stated in the Swedish description of competence for registered nurses with a graduate degree in nursing – specialized in anaesthetic care. ⁶ If surgical departments would enable preoperative encounters, similar to Lindwall and Von Post’s perioperative dialogue, ² NAs could establish a relationship, provide assurance and determine whether anxiolytics were required. The NA could then discuss it with the patient, which would maintain patient autonomy. The present study showed that increased experience facilitated medical interventions when required by the patient. However, there were contradictions among the informants. Some NAs felt that nursing interventions should be prioritized rather than medical interventions. Such an approach where actions are based on individual needs can be associated to caritas. ³

The findings showed that NAs experienced that patient anxieties were individual and could be caused by previous experiences of health care. Patients were generally anxious of undergoing anaesthesia, which was consistent with previous studies.^16,17 It emerged that inadequate information could cause patient anxiety. The findings were coherent with research regarding correlation between insufficient information and increased anxiety. ¹⁶ The current study showed that younger patients often searched for information on the Internet, which could lead to apprehension. An awareness of media influences should perhaps be included in the preoperative assessment. The informants experienced that patients could express anxiety over losing control of the situation, which was consistent with previous research. ¹⁸ It emerged that NAs experienced that anaesthesiologists’ perceptions of patient anxiety could sometimes diverge from those of the NA. Previous research has shown similar results. ²² The findings showed that this divergence could be an influential factor on the intraoperative meeting between NA and anxious patients. A recent study showed that an absence of vital information in the preoperative assessment could affect planning of nursing interventions. ¹¹ The informants expressed that changes in planned anaesthesia could cause apprehensions. Previous literature has shown that anaesthesiologists should include the patient in such changes. ³⁶

It emerged that it was easier with professional experience to address demanding encounters with anxious patients. NAs with increased experience felt that professional experience made it easier to distance oneself from problematic situations. The NAs expressed that their professional role was not established at the beginning of their career, and that at that stage they were more likely to regard an unsuccessful intraoperative meeting as personal failure. The findings can be compared to Benner, where the competent nurse can manage unexpected situations based on clinical experiences. ⁵ The theory supports the study’s essential finding of the importance of professional experience in addressing patient anxiety.

Conclusions

The most prominent finding was that having years of experience facilitated addressing anxiety in the intraoperative setting. Increased experience resulted in self-confidence, which could facilitate individualized care. The most evident difference was how NAs would address patient anxiety; either with medical or nursing interventions. The NAs aspired for pre-, intra- and postoperative encounters. A preoperative meeting could enable NAs to recognize anxiety at an early stage. A postoperative encounter could facilitate feedback, professional improvement and enable patients to ask questions, which could lead to assurance in the health care system. It would be aspiring to implement these conclusions in the clinical setting to optimize the first intraoperative encounter. In addition, further research on the effects of media on perioperative anxiety could be relevant, since self-research on the Internet is a modern-day global phenomenon. To conclude, this paper is important for aspiring or inexperienced NAs to obtain knowledge and understanding, considering patient anxiety is a common occurrence in perioperative nursing.